How to avoid Medicare CT scan payment denials

2014 08 29 09 35 55 499 Majchrzak Jeff 200

Like other federal government agencies, the U.S. Centers for Medicare and Medicaid Services (CMS) loves to study Medicare data because it helps to identify which services are prone to improper payments and, thus, may require additional action to ensure accurate billing. It also loves to compare billing patterns to determine which providers are outside of the norm for procedures performed.

Among the educational tools used by CMS are comparative billing reports (CBRs), which are developed under contract by eGlobalTech, a federal services firm based in Arlington, VA. CBRs contain actual data-driven tables and graphs, with an explanation of findings that compare the billing and payment patterns of healthcare providers to those of their peers on a national and state level.

Jeff Majchrzak of Panacea Healthcare Solutions.Jeff Majchrzak of Panacea Healthcare Solutions.

eGlobalTech distributes the CBRs to providers, who are encouraged to use them to glean insight into their individual billing practices and compare them with trends across regions and policy groups.

Relevant for radiologists

Through an analysis of Medicare Part B fee-for-service claims, eGlobalTech identified "rendering providers," including radiologists, with "different" billing patterns for CT of the pelvis and abdomen (CPT codes 74176-74178). Researchers reviewed claims for evidence of abuse, including the following:

  • Absence of reasonable indications
  • Excessive number of scans
  • Unnecessarily expensive types of scans

One of the CMS resources used by eGlobalTech researchers were the detailed appendices of the November 2014 Comprehensive Error Rate Testing (CERT) report, which provided the utilization rates -- and the ammunition -- for their choice of analysis:

  • 72192-72194, CT of pelvis: 191,623 services provided
  • 74150-74170, CT of abdomen: 364,748 services provided
  • 74176-74178, CT of abdomen/pelvis: 5,424,219 services provided

Table B1 of the CERT report includes the service types with highest number of Part B improper payments. The category titled "advanced imaging," which includes CT as well as CT angiography (CTA), showed that insufficient documentation (information missing from the medical record) caused more than 93% of improper payments. Missing orders caused more than half of the payment denials.

To prevent denials, be sure to document that you performed a CT scan. eGlobalTech lists the following as documentation requirements for imaging procedures:

  • Formal written, interpretive report
  • Name of interpreting provider
  • Reason for the test
  • Copies of all images
  • Written or electronic request for procedure that supports medical necessity

If you receive a documentation request from a Medicare review contractor, submit the order from the ordering practitioner. If the order has been misplaced and you cannot retrieve it, ask the ordering practitioner to send you the progress notes, plan of care, or any other medical record entry prior to the day of the CT scan that documents the intent to order it and why it was needed.

Bottom line

In the opinion of CMS, all providers should realize they have an obligation to ensure claims are submitted to Medicare correctly. Here are some ways to improve your odds of passing muster with CMS:

  • Become familiar with Medicare's national coverage determination (NCD) 220.1, which states that CT scans must be medically appropriate considering the patient's symptoms and preliminary diagnosis. Local coverage determinations (LCDs) for CT scans further define the circumstances demonstrating medical necessity.
  • Conduct a self-audit to identify coverage and coding errors.
  • Look at the details of the CBR, if you received one, and compare your individual data to that of CMS and peers.
  • Educate ordering physicians if you are receiving requests that lack medical necessity. According to eGlobalTech, orders should include:
    • Relevant medical history
    • Physical exam
    • Diagnosis (if known)
    • Pertinent signs and symptoms
    • Results of pertinent diagnostic tests and/or procedures

Additional CBR information is available here.

Jeff Majchrzak is vice president of clinical consulting services, radiology, for Panacea Healthcare Solutions. In his role as consultant, he conducts CPT coding assessments for both hospitals and physicians, evaluates administrative policies and procedures, and helps develop quality assurance programs to ensure complete and compliant coding and billing. Jeff trains both radiology and cardiology staff (on both technical and professional billing issues) in correct coding practices. Jeff contributes to numerous publications by MedLearn Publishing (a division of Panacea) and is a sought-after national speaker on coding and reimbursement for radiology, interventional radiology, nuclear medicine, and cardiology. Jeff can be reached at [email protected], or visit Panacea Healthcare Solutions at www.panaceahealthsolutions.com.

The comments and observations expressed herein are those of the author and do not necessarily reflect the opinions of AuntMinnie.com.

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